Rhinorrhea can be caused by nasal diseases or by systemic diseases. Mostly unilateral, in a few cases, bilateral nasal bleeding can occur; the amount of bleeding varies, light cases are only blood in the snot, heavy cases can cause hemorrhagic shock, repeated nasal bleeding can lead to anemia.
I. Etiology.
1.Local causes
(1) Nasal injury.
① Mechanical trauma such as car accidents, bruises, boxing injuries and nose digging are common causes of nasal bleeding.
② air pressure injury in the process of high-altitude flight, diving, if the difference in air pressure inside and outside the sinuses suddenly changes too much, will make the mucous membrane in the nasal cavity sinus vasodilatation rupture bleeding.
(3) Radiotherapy injury During and after radiotherapy of the head and neck, congestion and edema of the nasal mucosa occurs, or the epithelium is detached, and nasal bleeding may also occur.
(2) Deviated nasal septum: It mostly occurs near the bone crest or bone spine (momentary process) or the convex surface of the deviated nasal septum, where the mucosa is thin and the flow direction of airflow is changed here, so the mucosa becomes dry and the blood vessels rupture and bleed. In patients with nasal septal perforation, the dryness, erosion and dryness of the mucosa at the edge of the perforation can cause recurrent nasal bleeding.
(3) Nasal inflammation.
①Non-specific inflammation of the nose Acute rhinosinusitis, dry rhinitis, atrophic rhinitis, etc. are likely to cause rhinorrhea, and the amount of bleeding is usually not much.
(2) Specific infection of the nose Specific infections such as tuberculosis, lupus, syphilis, leprosy and diphtheria can cause nasal bleeding due to mucosal erosion, ulceration, granulation and perforation of the nasal septum.
(4) Nasal cavity, sinus and nasopharynx tumors: the most likely to occur nasal bleeding are nasal septal hemangioma, nasopharyngeal fibrovascular tumor, hemorrhagic nasal polyp and malignant tumor of nasal cavity and sinus. Small amount of nasal bleeding or blood in the snot is one of the main early symptoms of malignant tumors.
(5) Nasal foreign body: it is common in children, mostly unilateral nasal bleeding, because the nasal foreign body stays in the nasal cavity for a long time, it can cause nasal mucosa erosion and bleeding.
2.Systemic causes
(1) Bleeding diseases and blood disorders.
(1) Defective diseases of blood vessel wall structure and function Such as hereditary bleeding capillary dilation, vitamin C deficiency, allergic purpura, pharmacological vascular purpura, infectious vascular purpura, vascular pseudohemophilia, etc.
② Platelet count or dysfunctional diseases such as primary thrombocytopenic purpura, secondary thrombocytopenia due to various causes, etc.
(iii) Coagulation factor disorders such as various types of hemophilia, vitamin K deficiency, etc.
(iv) Excessive self-anticoagulation of blood Such as improper use of anticoagulants, presence of anticoagulant substances such as antifibrinogen in the blood circulation, or excessive or accelerated fibrinolysis, such as diffuse intravascular coagulation, etc.
(2) Acute febrile infectious diseases: such as epiglottitis, influenza, hemorrhagic fever, scarlet fever, malaria, measles and typhoid fever, etc. Mostly due to high fever, toxic damage to blood vessels, congestion, swelling and dryness of the nasal mucosa, resulting in capillary rupture and bleeding. In general, the amount of bleeding is small, mostly occurs during the febrile period, and the bleeding site is mostly located in the anterior part of the nasal cavity.
(3) Diseases of the cardiovascular system.
(1) Hypertension and arteriosclerosis Hypertension and arteriosclerosis are important causes of rhinorrhea in middle-aged and elderly people, and vascular sclerosis is its pathological basis. Increased blood pressure, especially during constipation, excessive force or emotional excitement, can rupture the nasal blood vessels and cause nasal bleeding. In addition, sneezing, forceful coughing, violent transnasal breathing or nasal massage are also factors that make nasal bleeding recurrent and difficult to control.
(2) Increased venous pressure Pulmonary emphysema, pulmonary heart disease, mitral stenosis, neck or mediastinal occupying lesions and other diseases can cause superior vena cava hypertension, the nasal cavity and nasopharyngeal veins of these patients are often angry stasis, when the patient coughs violently or other triggers, the blood vessels can rupture and bleed, the bleeding site is mostly located in the nasopharyngeal veins at the posterior nostril from the distribution area.
(4) Other systemic diseases: pregnancy, premenopause and menopause can cause rhinorrhea, which may be related to the increase of capillary fragility. Patients with severe liver disease can cause nasal bleeding due to impaired synthesis of coagulation factors by the liver. Uremia can also cause rhinorrhea. Rhinorrhea can be one of the early manifestations of rheumatic fever.
Clinical manifestations:
Most of the nasal bleeding is unilateral or bilateral; it can be intermittent and repeated, or continuous. The amount of bleeding varies, from a few drops or a few milliliters of blood in the snot in light cases to tens of milliliters or even hundreds of milliliters in heavy cases, leading to hemorrhagic shock. Repeated bleeding may lead to anemia. A small amount of bleeding may stop on its own or after self-compression.
Most of the bleeding sites occur in the bleeding-prone area of the lower anterior part of the nasal septum, and sometimes jet or pulsating small arterial bleeding can be seen; nasal bleeding in children and young people mostly occurs in this area. Nasal bleeding in middle-aged and elderly people is often related to hypertension and atherosclerosis, and the bleeding site is mostly found in the posterior part of the nasal cavity, the nasopharyngeal venous plexus near the posterior end of the inferior turbinate and the arteries in the posterior part of the nasal septum. Bleeding from this area is generally more violent and not easy to stop, and bleeding often flows rapidly into the pharynx and is spit out from the mouth.
Rhinorrhea caused by local disorders mostly occurs in one nasal cavity, while those caused by systemic diseases may bleed alternately or simultaneously in both nasal cavities.
III. Differential diagnosis.
1. Hemoptysis: blood is hemoptysis through the mouth after bleeding from the larynx, trachea, bronchus and lungs, commonly caused by pulmonary tuberculosis, bronchiectasis, lung cancer, lung abscess and pulmonary stasis due to heart disease. It can be identified based on the patient’s past medical history, physical signs and auxiliary examinations.
2, vomiting blood: vomiting blood is one of the main manifestations of upper gastrointestinal bleeding, when a large amount of vomiting blood, blood can gush out of the mouth and nasal cavity, often accompanied by other symptoms of gastrointestinal disease, the whole body examination can have positive signs, can be distinguished.
IV. Treatment.
Rhinorrhea is an emergency, and treatment should first maintain vital signs, stop bleeding as quickly as possible, and treat the cause.
1. General treatment: First of all, comfort the patient and family members who are nervous and fearful to calm them down so that the patient’s blood pressure will not rise due to mental factors, which will aggravate the bleeding, and take blood pressure and pulse rate in time, and rehydrate if necessary to maintain stable vital signs. If the patient is in shock, first aid should be given for shock. When taking medical history, ask about the following: which side of the nasal cavity bleeds or which side bleeds first, the speed and amount of bleeding, whether there is recurrent nasal bleeding in the past, whether there is any trigger for this bleeding, whether there are other accompanying symptoms, etc.
2.Find the bleeding point: according to the specific situation, perform local and general examination of the nasal cavity. When examining the nasal cavity, remove the clot in the nasal cavity, apply 1% ephedrine and dicaine to fully contract and anesthetize the nasal mucosa, and find the bleeding site as much as possible in order to stop the bleeding accurately. If available, it is best to find the bleeding point under nasal endoscopy and implement hemostatic treatment.
3.Nasal hemostasis method: according to the priority of bleeding, bleeding site, bleeding volume and etiology, choose different hemostatic methods.
(1) Acupressure method Patients can use fingers to pinch bilateral nasal wings or press the bleeding side of the nose to the nasal septum for 10 to 15 minutes, or use fingers to press the upper lip area transversely, while applying cold compresses to the forehead and the back of the neck. This method is suitable for patients with a small amount of bleeding and bleeding in the anterior part of the nasal cavity, and patients with nasal bleeding at home can take this method.
(2) Local hemostatic drugs Suitable for lighter bleeding in the anterior part of the nasal cavity, this method is simple and easy to use, and the patient suffers less pain. For the bleeding area, cotton tablets soaked with 1% ephedrine, 1‰ epinephrine, 3% hydrogen peroxide solution or thrombin can be applied and tightly plugged into the nasal cavity for several minutes to several hours to stop the bleeding.
(3) cautery method commonly used are chemical cautery and physical cautery (including electric cautery, laser cautery and microwave cautery, etc.). For bleeding located in the anterior and inferior part of the nasal septum, after adequate contraction and anesthesia of the nasal mucosa, the bleeding site is clearly visible, and the bleeding point can be cauterized with a roll of cotton dipped in a little 30 to 50% silver nitrate or 30% trichloroacetic acid, and pressed at the bleeding point for a few moments until a white film is formed locally.
(4) anterior nostril caulking anterior nasal active bleeding intense or bleeding site is not clear can be applied.
Vaseline oil gauze plugging of the anterior nostril is the traditional method to stop bleeding, most patients with nasal bleeding can stop bleeding after plugging, a few patients need repeated plugging or further posterior nostril plugging. Vaseline oil gauze can be filled from the top of the nasal cavity by folding it downward layer by layer, or from the bottom of the nose to the top of the nasal cavity, with a certain depth and strength when filling, and avoid stacking all the gauze strips in the anterior nostril. After filling, check whether there is still blood flowing into the oropharynx through the posterior nostril.
Depending on the situation, the time of removal of nasal stuffing should be decided. For patients with severe bleeding or hematological diseases, the time of stuffing should be extended appropriately, and antibiotics should be given to patients during the process of stuffing to prevent concurrent infection of nasal cavity and sinuses. In addition, other stuffing hemostatic materials such as expanded sponge, calcium alginate fiber, etc. can be used for diffuse, smaller amount of nasal mucosa bleeding, with the advantages of good hemostatic effect and less pain.
(5) Posterior nostril caulking If the bleeding does not stop after the anterior nostril caulking, and flows backward into the pharynx or gushes out from the contralateral nasal cavity, posterior nostril caulking should be chosen.
(6) Transnasal endoscopic hemostasis method With the progress of ear, nose and throat instruments, in recent years, the method of nasal endoscopic exploration of bleeding sites and electrocoagulation to stop bleeding has achieved remarkable results and is widely used, with an efficiency of more than 90%. Compared with Vaseline gauze stuffing, it greatly reduces the damage to the nasal mucosa and causes less pain to the patient. After hemostasis, no special care is needed, and complications are few, but the disadvantage is the higher cost.
(7) Arterial embolization The rapid development of imaging technology has helped in the diagnosis and treatment of severe nasal bleeding, and digital silhouette angiography (DSA) technology can locate the bleeding site and embolize the vessels in that area. This method can directly show the site and cause of bleeding, and the hemostatic effect is rapid and effective, shortening the treatment time. In critical situations with heavy bleeding, digital silhouette angiography embolization is an effective resuscitation measure. However, arterial embolization for nosebleeds requires certain equipment and conditions, high technical requirements, and greater costs for patients.
(8) Vascular ligation At present, it is generally used less frequently, and is mostly applied to those who have severe nasal bleeding and still cannot stop bleeding by all the above treatments. Before ligation, the source of bleeding should be judged correctly as far as possible before deciding which artery to ligate. Generally, ligation of the anterior septal artery is feasible for bleeding in the upper part of the nasal cavity; ligation of the maxillary artery or external carotid artery should be performed for bleeding in the lower part of the posterior nasal cavity.
(9) Nasal septal surgery Nasal septal mucosal scoring is indicated for recurrent nasal bleeding caused by dilatation of small blood vessels in the lower anterior part of the nasal septum. Under local anesthesia, the mucosa of the nasal septum is scratched to destroy the dilated small blood vessel network to achieve the effect of preventing recurrent nasal bleeding. Laser and radiofrequency can also be used to destroy the dilated small vascular network. For nasal bleeding caused by deviated nasal septum, septal correction is feasible.
(10) Other surgery For nasal bleeding caused by nasal cavity or sinus tumor, depending on the specific situation and the nature of the tumor or first stop the bleeding, or surgically remove the tumor, or use radiotherapy, or ligate the blood vessels in the neck to stop the bleeding.
4.Systemic treatment
There are many causes of nasal bleeding, and the degree of bleeding is also different. The treatment and treatment of nasal bleeding cannot only stop nasal bleeding, but also take the necessary systemic basic and special treatment according to the condition, that is, actively treat the original disease during the period of hemostasis.
(1) Find the cause of bleeding and carry out etiological treatment.
(2) Evaluation of bleeding volume should be performed in all patients with nasal bleeding, and it is especially important for patients who are still actively bleeding at the time of consultation.
(3) In elderly patients or those with more bleeding, attention should be paid to the presence of hemorrhagic anemia, shock and cardiac damage, and prompt treatment. Patients with large bleeding should also be tested for blood type and blood preparation, and treated with rehydration and blood transfusion according to the amount of blood loss. For elderly patients, blood pressure should not be lowered too fast to avoid thrombosis.
(4) Nasal and posterior nostril occlusion can lower the partial pressure of oxygen and increase the partial pressure of carbon dioxide, so the elderly patients should pay attention to the function of the heart, lungs and brain, and give oxygen if necessary.
(5) Appropriate application of systemic hemostatic drugs, such as thrombin, aminoglycolic acid, phenolsulfonamide, etc.
(6) For emotionally stressed patients, appropriate sedative drugs can be applied, and psychotherapy can play a great role in reducing patients’ tension and anxiety and preventing re-bleeding.
V. Prevention.
Usual attention should be paid to the prevention of nasal bleeding, measures include.
1, keep the room quiet, clean, the temperature should be appropriate. Keep the indoor air fresh, open the windows properly for ventilation, the temperature should be kept at 18-20 ℃. Because the air is too dry can induce nasal bleeding, so the air humidity should be ≥ 60%.
2.The elderly should move slowly when moving around on weekdays, do not blow their noses hard, and stop coughing symptomatically.
3, the diet should be into some easy to digest soft food, eat more fruits and vegetables, avoid spicy and stimulating diet, and keep the bowel movement smooth, constipation can be given laxative.
4.Patients with senile rhinorrhea are mostly accompanied by hypertension, coronary heart disease and bronchitis, etc. They should regularly prevent and control the original disease, and must carry out corresponding treatment for the cause, especially for patients with hypertension, they must control their blood pressure to normal or near-normal level as soon as possible, observe the changes in their condition, and go to the hospital in time.
5, for children with rhinorrhea should correct the child digging nose, rubbing nose, curious placement of foreign objects and other bad habits that can easily lead to mucosal damage.